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3153 Psychiatry > IC10 Schizophrenia & Psychosis > Flashcards

IC10 Schizophrenia & Psychosis Flashcards

1
Q

What are the symptoms of schizophrenia?

A
  • Positive symptoms (hallucinations/delusions)
    o Hallucinations – perceptual experiences without stimulations
    o Delusions – fixated on a belief that is not true
  • Negative symptoms (great loss of interest)
  • Functional impairment
  • Protracted Psychosis – last for a long time, about >6 months and will not stop
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2
Q

What needs to be ruled out before diagnosing someone as schizophrenic?

A

Rule out:

  • organic disorders
    o e.g. iatrogenic causes,
    o psychosis related to alcohol / psychoactive substance misuse such as BZD, anti-depressants, corticosteroids, CNS stimulants
  • mood/affective disorders e.g. depression, bipolar disorder, mania, post-partum psychosis
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3
Q

What is the cause of schizophrenia (patho)?

A
  • dysregulation of 5-HT, Dopamine and glutamate functions
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4
Q

What is the DSM-5 criteria for schizophrenia?

A

DSM- 5 criteria for schizophrenia:

  1. 2 or more of the following for at least 1 month
    a. Hallucination
    b. Delusions
    c. Disorganized speech
    d. Grossly disorganized / catatonic behaviour (reacts very little)
    e. Negative symptoms
  2. Social/ work functioning significantly decreased
  3. S&S continued for at least 6 months
  4. Disorder not due to medical disorder or substance use
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5
Q

What are the non-pharm management?

A

Non-pharmacological Management:

  1. Cognitive Behavioral Therapy (CBT) ?
    a. Help patients learn how to manage problems by changing the way they think and behave
    b. Used together with medications and family interventions
  2. Supportive counselling
  3. Social skill therapies
  4. Rehab
  5. Vocational training etc.
  6. Electroconvulsive therapy (ECT)
    a. For treatment-resistant schizophrenia
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6
Q

What is the drug class that we use for schizophrenia?

A

Anti-psychotics

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7
Q

What does antipsychotics help with? How is it better than the BZDs? What is its place in therapy for schizophrenia (long term or short term)?

A

Pharmacological Management: Anti-psychotics (aka Thought Organizer)

  • Tranquilizes without impairing consciousness (vs BZDs which knocks them out) and without causing paradoxical excitement (vs BZDs which causes more agitation)
  • Action:
    o Relieve symptoms of psychosis (e.g. thought disorder, hallucinations and delusions) + prophylaxis
    o Long term treatment necessary since without it most will relapse
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8
Q

Why are relapse often delayed when you stop antipsychotic meds for schizophrenia?

A

Relapse are often delayed after cessation of treatment

  • Because adipose tissue act as a depot reservoir after chronic regular use of antipsychotics. Antipsychotics are stored in fat cells, then diffuses back into bloodstream after treatment cessation
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9
Q

What pathway does antipsychotics work on thus giving it its efficacy?
Which symptom(s) does it work on?

A

Efficacy:

  • Mesolimbic pathway – block D2 receptors thus reduce +ve symptoms of schizophrenia
  • FGA & SGA –> both can improve +ve symptoms via D2 antagonism in mesolimbic tract
  • SGA only –> may also improve -ve symptoms via 5-HT2 antagonism
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10
Q

What are the pathways that antipsychotics affect that causes them to have their ADRs?

A

ADRs:

  • FGAs –> EPSE (more than SGAs)
    Nigrostriatal pathway (body movement) – block dopamine receptors thus EPSE
  • SGAs
     Metabolic SE (more than FGAs except Aripiprazole, brexpiprazole, Cariprazine, lurasidone, ziprasidone)
     SGAs ending with “-ines” e.g. clozapine, olanzapine, quetiapine, generally more sedating & weight gain
    Tuberoinfundibular pathway (prolactin) - hyperprolactinemia
    o Mesocortical pathway (higher order thinking and executive functions) – block Dopamine thus results in -ve symptoms of schizophrenia
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11
Q

Which antipsychotics have more sedating and weight gain SE?

A

SGAs ending with “-ines” e.g. clozapine, olanzapine, quetiapine

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12
Q

Which 2nd gen antipsychotics do not have metoblic SE?

A

Aripiprazole, brexpiprazole

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13
Q

What is the PK of antipsychotics?

A

PK of PO antipsychotics

  • Most have short Tmax of 1-3hrs except Brexpiprazole, aripiprazole, olanzapine
  • Most have long t1/2 thus QD, but some need to be given in divided doses due to their high risk of causing hypotension and seizures e.g. CPZ, clozapine, quetiapine, Amisulpride
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14
Q

Which antipsychotics need to be given in divided doses?

A

CPZ, clozapine, quetiapine, Amisulpride

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15
Q

List exmaples of high potency and low potency antipsychotics.

A
  • High potency antipsychotics: haloperidol, olanzapine, risperidone
  • Low potency antipsychotics: chlorpromazine, Amisulpride, clozapine, quetiapine
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16
Q

What is the duration of the antipsychotics when we first initiate it before we can see results?

A
  • Duration of antipsychotic trial: at least 2-6 weeks at therapeutic dose; clozapine needs 3 months
17
Q

What are the adjunctive medications we can give to antipsychotics?

A

Adjunctive treatment: BZD (help w agitation/sleep), Anti-depressant (for depression)

18
Q

Define treatment resistant schizophrenia.
What can we give to treat it?
What do we need to monitor?

A

Treatment Resistance Schizophrenia (TRS)

  • Not responsive to at least 2 adequate trials of anti-psychotics, of which one is a SGA
  • Duration of antipsychotic trial: at least 2-6 weeks at therapeutic dose; clozapine needs 3 months
  • Clozapine is licensed drug of choice for TRS
    o Monitor baseline and periodic FBC due to risks for agranulocytosis
  • If still no response, clozapine + FGA/SGA/ECT
19
Q

What is the treatment / algorithm for acute stabilization of schizophrenia?

A

Acute Stabilization Phase

  • Goal: minimize acute symptoms, minimize threat to self and others, reduce agitation, aggression, hostility, improve sleep
  • If acutely agitated/aggressive, patient cooperative:
    o 1st: de-escalate
    o 2nd: consider oral anti-psychotics +/- BZD
    Oral Lorazepam 1-2mg OR
     Oral Antipsychotic e.g. PO Haloperidol + ECG, PO Risperidone, PO Quetiapine, PO Olanzapine
  • 3rd: if uncooperative, refuse or impossible to administer oral meds
     Consider fast acting IM alternatives + Monitoring
    –> IM Haloperidol 5mg + ECG + IM Lorazepam 2mg** OR
    –> **    IM Haloperidol + ECG + IM Promethazine    (anti-histamine)
    o 4th: Monitor for treatment-emergent ADRs:
    Dystonia, pseudo-parkinsonian SE e.g. EPSE –> treat accordingly e.g. PO/IM Benztropine 2mg (anti-cholinergic)
     Others: BP, HR, RR, Oximetry, Tdegree, pain, I/O chart, hydration status
    o IF catatonia: give BZD e.g. PO/IM Lorazepam
20
Q

What to do during the stabilization/maintenance phase?
What to give when patients are non-adherent?

A

Stabilization & Maintenance Phase

  • Goal: minimize/prevent relapse, promote adherence, maintain baseline functioning
  • Monitor and manage ADRs
  • If poor adherence to PO medications, or if patients prefer IM consider:
    o IM Long-acting anti-psychotics (LAI) e.g. IM Haloperidol Deaconate, IM risperidone long acting (need to add on PO risperidone during 1st 3wks)
    o Community Psychiatric Nurse Referral
    o Patient and family education
21
Q

How to manage dystonia/tremors/rigidity? What drug usually causes this?

A

a. SE: Dystonia, tremors/rigidity
i. Common in: high potency e.g. Haloperidol
ii. Management:
1. Anticholinergics e.g. benztropine, diphenhydramine;
2. OR BZDs to relax muscles
3. OR switch to lower potency anti-psychotics/SGAs e.g. Quetiapine, sulpride

22
Q

How to manage akathisia? What drugs usually cause this?

A

b. SE: Akathisia (restless)
i. Common in: high potency antipsychotics e.g. haloperidol
ii. Management: Clonazepam and/or propranolol (beware of bradycardia, hypotension); OR switch to SGA/lower potency anti-psychotics

23
Q

How to manage tardive dyskinesia? What drugs causes this?

A

c. SE: Tardive Dyskinesia (irreversible if detected late in advanced stages)
i. Common in: FGAs, worsens with anti-cholinergics
ii. Management: stop any anticholinergics AND switch to low potency SGA; OR treat with valbenazine

24
Q

How to manage hyperprolactinemia? What drugs usually cause this?

A
  1. Hyperprolactinemia
    a. SE: breast pain, swelling, lactation, gynecomastia
    b. Common in: FGAs, paliperidone, amisulpride
    c. Management: switch to aripiprazole, OR dopamine agonist e.g. bromocriptine
25
Q

How to manage metabolic SE? What drugs cause this?

A
  1. Metabolic SE
    a. SE: weight gain, ↑ fasting lipids, glucose profiles
    b. Common in: Olanzapine, clozapine (*LOW in aripiprazole)
    c. Management: keep current anti-psychotics to prevent relapse but treat the emergent DM/dyslipidemia with lifestyle + meds e.g. Metformin/statins; OR switch to Aripiprazole, brexpiprazole, cariprazine, lurasidone, haloperidol
26
Q

How to manage daytime sedation? What drugs usually cause this?

A
  1. Daytime Sedation
    a. CPZ, clozapine, quetiapine
    b. Management: Administer in early evening e.g. 7pm for sedation to wear off; OR may consolidate to once-nightly dosing if possible (BUT NOT FOR clozapine, chlorpromazine, quetiapine –> seizure, hypotension –> thus give in divided doses)
27
Q

How to manage dizziness? What drugs cause it?

A
  1. Dizziness (orthostatic hypotension)
    a. Common in: CPZ, clozapine, risperidone, paliperidone, quetiapine
    b. Management: Rise up slowly from lying/sitting position, don’t increase dose too fast, monitor BP
28
Q

How to manage neuroleptic malignant syndrome?
What causes it?
What are the SE of this syndrome?

A
  1. Neuroleptic malignant syndrome (rare but very serious)
    a. SE: fever, ↑ CK, confusion, lead-pipe rigidity, ↑ PR, ↑ BP
    b. Due to: 1) Succinyl choline (muscle relaxant) 2) Use of antipsychotics 3) Sudden discontinuation of levodopa
    c. Management: Admit to A&E IMMEDIATELY, IV dantrolene diluted with water, switch to SGA
29
Q

How to manage agranulocytosis? What drug causes it?

A
  1. Agranulocytosis (clozapine)
    a. SE: ↓WBC, ↓absolute neutrophil count
    b. Management: Admit to A&E IMMEDIATELY, discontinue clozapine
30
Q

What are the general ADR differences between FGA and SGA?

A

ADRs of FGA – EPSE, hyperprolactinemia
ADRs of SGA – weight gain, metabolic SE

31
Q

What do you monitor for efficacy and ADRs? What is the treatment response timeline?

A

Monitoring for efficacy:

  • MSE

Monitoring of ADRs:

  1. BMI (q1month for 6months, then q3months)
  2. Fasting blood sugar (q3months when start, then annually)
  3. Lipid panel (q3months when start, then q6months)
  4. BP (q3months when start, then q6months)
  5. EPSE Exam (1st 2wks when start, then q3/6/12months)
  6. WBC & ANC for clozapine (weekly for 1st 18wks then monthly)

Treatment response:

  • 1wk – ↓agitation
  • 2-4wks – ↓paranoia, hallucination
  • 6-12wks – ↓delusions
32
Q

What are the CI and precautions when taking antipsychotics?

A

Contraindication:

  1. QTc prolongation (need to do ECG); especially haloperidol causes this

Precaution:

  1. Parkinson’s disease
  2. Agranulocytosis esp. for clozapine
  3. Elderly with dementia (increased risk of mortality and stroke)
33
Q

What precaution do you have to take when giving antipsychotics for elderly?

A

Elderly

  • Avoid drugs with alpha-adrenergic blockade (hypotension) / anti-cholinergic SE (constipation, urinary retention, dry mouth, delirium)
  • Start low, go slow
34
Q

Which antidepressant drugs have few CYP interactions?

A

Fewer CYP interactions: Mirtazapine, Escitalopram, venlafaxine, desvenlafaxine, vortioxetine

35
Q

What are the DDIs of antipsychotics?

A

DDI:

  1. CNS depressants – alcohol, opioids, BZDs
  2. Drugs with antimuscarinic, antihistaminic, alpha1-adrenergic blockade or dopamine blockade
  3. Dopamine agonist – levodopa, bromocriptine
  4. Antihypertensives
  5. CYP1A2 inducers – smoking
  6. CYP1A2 inhibitors – fluvoxamine, quinolones, macrolides
  7. Agranulocytosis – CBZ

3153 Psychiatry (10 decks)

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